Provider Demographics
NPI:1184054710
Name:HUMPHRIES, DAVID MADISON (CADC I/CRM II)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MADISON
Last Name:HUMPHRIES
Suffix:
Gender:
Credentials:CADC I/CRM II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:971-260-0355
Practice Address - Street 1:355 NW DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5523
Practice Address - Country:US
Practice Address - Phone:971-225-6695
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-CRM-II-011101YA0400X
OR14-07-06101YA0400X, 101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500699779Medicaid
OR500730604Medicaid